Medical Issues Associated with Anabolic Steroid Use: Are They Exaggerated?

Abstract

For the past 50 years anabolic steroids have been at the forefront of the controversy surrounding performance enhancing drugs. For almost half of this time no attempt was made by sports governing bodies to control its use, and only recently have all of the major sports governing bodies in North America agreed to ban from competition and punish athletes who test positive for anabolic steroids. These punitive measures were developed with the primary concern for promotion of fair play and eliminating potential health risks associated with androgenic-anabolic steroids. Yet, controversy exists whether these testing programs deter anabolic steroid use. Although the scope of this paper does not focus on the effectiveness of testing, or the issue of fair play, it is of interest to understand why many athletes underestimate the health risks associated from these drugs. What creates further curiosity is the seemingly well-publicized health hazards that the medical community has depicted concerning anabolic steroid abuse. Is there something that the athletes know, or are they simply naive regarding the dangers? The focus of this review is to provide a brief history of anabolic steroid use in North America, the prevalence of its use in both athletic and recreational populations and its efficacy. Primary discussion will focus on health issues associated with anabolic steroid use with an examination of the contrasting views held between the medical community and the athletes that are using these ergogenic drugs. Existing data suggest that in certain circumstances the medical risk associated with anabolic steroid use may have been somewhat exaggerated, possibly to dissuade use in athletes.

Full text

©Journal of Sports Science and Medicine (2006) 5, 182-193
http://www.jssm.org
Review article
MEDICAL ISSUES ASSOCIATED WITH ANABOLIC STEROID
USE: ARE THEY EXAGGERATED?
Jay R. Hoffman  and Nicholas A. Ratamess
The College of New Jersey, Ewing, NJ, USA
Received: 10 February 2006 / Accepted: 09 March 2006 / Published (online): 01 June 2006
ABSTRACT
For the past 50 years anabolic steroids have been at the forefront of the controversy surrounding
performance enhancing drugs. For almost half of this time no attempt was made by sports governing
bodies to control its use, and only recently have all of the major sports governing bodies in North America
agreed to ban from competition and punish athletes who test positive for anabolic steroids. These punitive
measures were developed with the primary concern for promotion of fair play and eliminating potential
health risks associated with androgenic-anabolic steroids. Yet, controversy exists whether these testing
programs deter anabolic steroid use. Although the scope of this paper does not focus on the effectiveness
of testing, or the issue of fair play, it is of interest to understand why many athletes underestimate the health
risks associated from these drugs. What creates further curiosity is the seemingly well-publicized health
hazards that the medical community has depicted concerning anabolic steroid abuse. Is there something
that the athletes know, or are they simply naïve regarding the dangers? The focus of this review is to
provide a brief history of anabolic steroid use in North America, the prevalence of its use in both athletic
and recreational populations and its efficacy. Primary discussion will focus on health issues associated
with anabolic steroid use with an examination of the contrasting views held between the medical
community and the athletes that are using these ergogenic drugs. Existing data suggest that in certain
circumstances the medical risk associated with anabolic steroid use may have been somewhat exaggerated,
possibly to dissuade use in athletes.
KEY WORDS: Androgens, ergogenic aids, athletes, sport supplements, performance enhancing drugs.
INTRODUCTION
Anabolic-androgenic steroids (herein referred to as
only anabolic steroids) are the man-made derivatives
of the male sex hormone testosterone.
Physiologically, elevations in testosterone
concentrations stimulate protein synthesis resulting
in improvements in muscle size, body mass and
strength (Bhasin et al., 1996; 2001). In addition,
testosterone and its synthetic derivatives are
responsible for the development and maturation of
male secondary sexual characteristics (i.e. increase
in body hair, masculine voice, development of male
pattern baldness, libido, sperm production and
aggressiveness).
Testosterone was isolated in the early 20th
century and its discovery led to studies
demonstrating that this substance stimulated a strong
positive nitrogen balance in castrated dogs and rats
(Kochakian, 1950). Testosterone, because of its
rapid degradation when given through either oral or
parenteral administration, poses some limitations as
an ergogenic aid. Although its potency is rapidly
observed, the high frequency of administration
needed becomes problematic. In addition,
testosterone has a therapeutic index of 1 meaning
there is similarity in the proportion between the
anabolic and androgenic effects. As a result it
becomes necessary to chemically modify
testosterone to retard the degradation process and

Medical issues and anabolic steroids
183
reduce some of the negative side effects. This allows
for maintenance of effective blood concentrations
for longer periods of time, may increase its
interaction with the androgen receptor, and achieves
the desired anabolic and androgenic changes.
Boje (1939) was the first to suggest that
exogenous testosterone administration may enhance
athletic performance. By the late 1940’s and 1950’s
testosterone compounds were experimented with by
some west coast bodybuilders (Yesalis et al., 2000).
The first dramatic reports of anabolic steroid use
occurred following the 1954 world weightlifting
championships (Yesalis et al., 2000). Use of these
drugs spread quickly through the 1960’s and became
popular among athletes in a variety of Olympic
sports (Dubin, 1990). Wide spread use has also been
reported in power lifters (Wagman et al., 1995),
National Football League players (Yesalis et al.,
2000), collegiate athletes (Yesalis, 1992), and recent
claims of wide spread use in many sports including
Major League Baseball players has made anabolic
steroids the number one sports story of 2005 in some
markets (Quinn, 2006). The ergogenic effects
associated with anabolic steroids are presented in
Table 1.
Table 1. Ergogenic effects associated with anabolic
steroid use.
Increase in lean body mass
Increase in muscle cross-sectional area
Decrease in body fat percent
Increase muscle strength & power
Enhance recovery between workouts
Enhance recovery from injury
Increase in protein synthesis
Increase in muscle endurance
Increase in erythropoiesis, hemoglobin,
and hematocrit
Increase in bone mineral density
Increase in glycogen storage
Increase in lipolysis
Increase in neural transmission
Reduced muscle damage
Increase in pain tolerance
Behavior modification (aggression)
Athletes typically use anabolic steroids in a
“stacking” regimen, in which they administer several
different drugs simultaneously. The rationale for
stacking is to increase the potency of each drug.
That is, the potency of one anabolic agent may be
enhanced when consumed simultaneously with
another anabolic agent. They will use both oral and
parenteral compounds. Most users will take anabolic
steroids in a cyclic pattern, meaning the athletes will
use the drugs for several weeks or months and
alternate these cycles with periods of discontinued
use. Often the athletes will administer the drugs in a
pyramid (step-up) pattern in which dosages are
steadily increased over several weeks. Towards the
end of the cycle the athlete will ‘step-down’ to
reduce the likelihood of negative side effects. At this
point, some athletes will discontinue drug use or
perhaps initiate another cycle of different drugs (i.e.,
drugs that may increase endogenous testosterone
production to prevent the undesirable drop in
testosterone concentrations that follows the removal
of the pharmaceutical agents). A recent study has
shown that the typical steroid regimen involved 3.1
agents, with a typical cycle ranging from 5 – 10
weeks (Perry et al., 2005). The dose that the athlete
administers was reported to vary between 5 - 29
times greater than physiological replacement doses
(Perry et al., 2005). These higher pharmacological
dosages appear necessary to elicit the gains that
these athletes desire. In a classic study on the dose-
response curve of anabolic steroids, Forbes (1985)
demonstrated that the total dose of anabolic steroids
have a logarithmic relationship to increases in lean
body mass. These results exacerbate the athlete’s
philosophy that if a low dose is effective, then more
must be better.
Adverse effects associated with anabolic
steroid use are listed in Table 2. For years, the
medical and scientific communities attempted to
reduce anabolic steroid use by athletes by
underscoring their efficacy and focusing on the
unhealthy side effects (Biely, 1987; Darden, 1983;
Fahey and Brown, 1973; Fowler et al., 1965;
Golding et al., 1974). For the most part, this may
have proved to be ineffective and caused athletes to
lose trust in the physician’s knowledge of anabolic
steroids thereby forcing them to seek advice from
friends, internet sites or drug suppliers (Pope et al.,
2004). However, recent literature has suggested that
the medical issues associated with anabolic steroids
may be somewhat overstated (Berning et al., 2004;
Sturmi and Diorio, 1998; Street et al., 1996)
considering that many of the side effects associated
with anabolic steroid abuse are reversible upon
cessation. It is important to note that there are
differences in the side effects associated with
anabolic steroid use (i.e. under medical supervision)
versus abuse (i.e. consumption of many drugs at
high doses).
The clinical examination of anabolic steroid
use is quite limited. Much of the problem in
prospectively examining the effects of anabolic
steroids on the athletic population is related to the
unwillingness of institutional review boards to
approve such studies in a non-clinical population. As
a result, most of the investigations concerning

Hoffman and Ratamess
184
Table 2. Adverse effects associated with anabolic steroid use.
Cardiovascular
Lipid profile changes
Elevated blood pressure
Decreased myocardial function
Dermatological
Acne
Male pattern baldness
Endocrine
Gynecomastia
Decreased sperm count
Testicular atrophy
Impotence and transient infertility
Hepatic
Increased risk of liver tumors and
liver damage
Musculoskeletal
Premature epiphyseal plate closure
Increased risk of tendon tears
Intramuscular abscess
Genitourinary
Males
Reduced sperm counts
Decreased testicular size
Females
Menstrual irregularities
Clitoromegaly
masculinization
Males and Females
Gynecomastia
Libido changes
Psychological
Mania
Depression
Aggression
Mood swings
medical issues associated with anabolic steroid
administration have been performed on athletes self-
administering the drugs. Anecdotally, it appears that
a disproportionate magnitude of use and incidence of
adverse effects are evident in bodybuilders (who are
also known for consuming several other drugs that
relieve some side effects but potentiate other risk
factors as well, i.e. diuretics, thyroid hormones,
insulin, anti-estrogens, etc.) compared to
strength/power athletes. The mindset and motivation
of these two types of athletes can be quite different.
The strength/power athlete will typically use
anabolic steroids to prepare themselves for a season
of competition. They will generally cycle the drug to
help them reach peak condition at a specific time of
the training year. In contrast, bodybuilders use
anabolic steroids to enhance muscle growth and
definition. Their success is predicated on their
aesthetic appearance. As a result many of these
athletes may use anabolic steroids excessively for
several years without cycling off or perhaps
minimizing the length of “off cycles” depending on
their competition schedule. Recent research has
indicated that those athletes exhibit behavior that are
consistent with substance dependence disorder
(Perry et al., 2005). Although the medical issues
associated with anabolic steroids may be quite
different between these two types of athletes, the
scientific literature generally does not differentiate
between the two. The following sections will discuss
adverse effects on specific physiological systems
associated with anabolic-androgenic steroid use. It is
important to note that many athletes consume
multiple drugs in addition to anabolic steroids. Thus,
the unhealthy side effects could be potentiated by
the use of drugs such as human growth hormone or
IGF-1.
CARDIOVASCULAR SYSTEM
In both the medical and lay literature one of the
principal adverse effects generally associated with
anabolic steroid use is the increased risk for
myocardial infarction. This is primarily based upon
several case reports published over the past 20 years
describing the occurrence of myocardial infarctions
in young and middle-aged body builders or weight
lifters attributed to anabolic steroid use and/or abuse
(Bowman, 1989; Ferenchick and Adelman, 1992;
Gunes et al., 2004; Kennedy and Lawrence, 1993;
Luke et al., 1990; McNutt et al., 1988). However,
direct evidence showing cause and effect between
anabolic steroid administration and myocardial
infarction is limited. Many of the case studies
reported normal coronary arterial function in
anabolic steroid users that experienced an infarct
(Kennedy and Lawrence, 1993; Luke et al., 1990),
while others have shown occluded arteries with
thrombus formation (Ferenchick and Adelman,
1992; Gunes et al., 2004; McNutt et al., 1988). Still,
some of these studies have reported abnormal
lipoprotein concentrations with serum cholesterol
levels nearly approaching 600 mg·dl-1 (McNutt et al.,
1988). Interestingly, in most case studies the effects
of diet or genetic predisposition for cardiovascular
disease were not disseminated and could not be
excluded as contributing factors.

Medical issues and anabolic steroids
185
Alterations in serum lipids, elevations in blood
pressure and an increased risk of thrombosis are
additional cardiovascular changes often associated
with anabolic steroid use (Cohen et al., 1986; Costill
et al., 1984; Dhar et al., 2005; Kuipers et al., 1991;
Laroche, 1990). The magnitude of these effects may
differ depending upon the type, duration, and
volume of anabolic steroids used. Interesting to note
is that these effects appear to be reversible upon
cessation of the drug (Dhar et al., 2005, Parssinen
and Seppala, 2002). In instances where the athlete
remains on anabolic steroids for prolonged periods
of time (e.g ”abuse”), the risk for developing
cardiovascular disease may increase. Sader and
colleagues (2001) noted that despite low HDL levels
in bodybuilders, anabolic steroid use did not appear
to cause significant vascular dysfunction.
Interestingly, athletes participating in power sports
appear to have a higher incidence of cardiovascular
dysfunction than other athletes, regardless of
androgen use (Tikkanen et al., 1991; 1998). Thus, a
strength/power athlete with underlying
cardiovascular abnormalities that begins using
anabolic steroids is at a much higher risk for
cardiovascular disease. However, anabolic steroid-
induced changes in lipid profiles may not, per se,
lead to significant cardiovascular dysfunction.
The risk of sudden death from cardiovascular
complications in the athlete consuming anabolic
steroids can occur in the absence of atherosclerosis.
Thrombus formation has been reported in several
case studies of bodybuilders self-administering
anabolic steroids (Ferenchick, 1991; Fineschi et al.,
2001; McCarthy et al., 2000; Sahraian et al., 2004).
Melchert and Welder (1995) have suggested that the
use of 17α-alkylated steroids (primarily from oral
ingestion) likely present the highest risk for
thrombus formation. They hypothesized that
anabolic steroid consumption can elevate platelet
aggregation, possibly through an increase in platelet
production of thromboxane A2 and/or decreasing
platelet production of prostaglandin PgI2, resulting
in a hypercoagulable state.
Left ventricular function and anabolic steroid
use/abuse has been examined. Climstein and
colleagues (2003) demonstrated that highly strength-
trained athletes, with no history of anabolic steroid
use exhibited a higher incidence of wave form
abnormalities relative to recreationally-trained or
sedentary individuals. However, when these athletes
self-administered anabolic steroids, a higher
percentage of wave form abnormalities were
exhibited. Further evidence suggestive of left
ventricular dysfunction has been reported in rodent
models. A study on rats has shown that 8 weeks of
testosterone administration increased left ventricle
stiffness and caused a reduction in stroke volume
and cardiac performance (LeGros et al., 2000). It
was hypothesized that the increased stiffness may
have been related to formation of crosslinks between
adjacent collagen molecules within the heart. Others
have suggested that anabolic steroid use may
suppress the increases normally shown in
myocardial capillary density following prolonged
endurance training (Tagarakis et al., 2000).
However, there are a number of interpretational
issues with this study. The changes reported were
not statistically significant. In addition, the exercise
stimulus employed (prolonged endurance training) is
not the primary mode of exercise frequently used by
anabolic steroid users. Resistance training,
independent of anabolic steroid administration, has
been shown to increase left ventricular wall and
septal thickness due to the high magnitude of
pressure overload (Fleck et al., 1993; Fleck, 2003;
Hoffman, 2002). This is known as concentric
hypertrophy and does not occur at the expense of left
ventricular diameter. In general, cardiac hypertrophy
(resulting from a pressure overload, i.e.
hypertension) may not be accompanied by a
proportional increase in capillary density (Tomanek,
1986). Therefore, the potential for a reduction in
coronary vasculature density exists for the
resistance-trained athlete. However, it does not
appear to pose a significant cardiac risk for these
athletes. Recent observations have shown a dose-
dependent increase in left ventricular hypertrophy
(LVH) in anabolic steroid users (Parssinen and
Seppala, 2002). This may have the potential to
exacerbate the reduction in coronary vasculature
density. However, the authors have acknowledged
that their results may have been potentiated by a
concomitant use of human growth hormone by their
subjects. Other studies have failed to show additive
effects of anabolic steroid administration and LVH
in resistance-trained athletes (Palatini et al., 1996;
Dickerman et al., 1998).
HEPATIC SYSTEM
An elevated risk for liver tumors, damage,
hepatocellular adenomas, and peliosis hepatitis are
often associated with anabolic steroid use or abuse.
This is likely due to the liver being the primary site
of steroid clearance. In addition, hepatic cancers
have been shown to generally occur with higher
frequency in males compared to females (El-Serag,
2004). It is thought that high endogenous
concentrations of testosterone and low estrogen
concentrations increase the risk of hepatic
carcinomas (Tanaka et al., 2000). However, this
appears to be prevalent for men with pre-existing

Hoffman and Ratamess
186
liver disease. In normal, healthy men the relationship
between testosterone concentrations and liver cancer
has not been firmly established. Additional reports
of liver cancer and anabolic steroids have been
reported in non-athletic populations being treated
with testosterone for aplastic anemia (Nakao et al.,
2000). In regards to liver cancer and disease in
athletes consuming anabolic steroids, many concerns
have been raised based primarily on several case
studies that have documented liver disease in
bodybuilders using anabolic steroids (Cabasso,
1994; Socas et al., 2005; Soe et al., 1992).
A few studies have recently questioned the
risk to hepatic dysfunction from anabolic steroid use
(Dickerman et al., 1999). A recent study examining
the blood chemistry of bodybuilders self-
administering anabolic steroids reported elevations
in aspartate aminotransferase (AST), alanine
aminotransferase (ALT) and creatine kinase (CK),
but no change in the often-regarded more sensitive
gamma-glutamyltranspeptidase (GGT) concentration
(Dickerman et al., 1999). Thus, some experts have
questioned these criteria tools because of the
difficulty in dissociating the effects of muscle
damage resulting from training from potential liver
dysfunction. This has prompted some researchers to
suggest that steroid-induced hepatotoxicity may be
overstated. Another study involved a survey sent to
physicians asking them to provide a diagnosis for a
28-year-old anabolic steroid using bodybuilder with
abnormal serum chemistry profile (elevations in
AST, ALT, CK, but with a normal GGT) (Pertusi et
al., 2001). The majority of physicians (63%)
indicated liver disease as the primary diagnosis as
56% of physicians failed to acknowledge the
potential role of muscle damage or disease thereby
increasing the likelihood of overemphasized
anabolic steroid-induced hepatotoxicity diagnoses.
Many case reports involving anabolic steroid
administration and hepatic cancers examined
individuals who were treated with oral steroids
(17α-alkylated) for many years. No cysts or tumors
have been reported in athletes using 17β-alkylated
steroids. Thus, evidence appears to indicate that the
risk for hepatic disease from anabolic steroid use
may not be as high as the medical community had
originally thought although a risk does exist
especially with oral anabolic steroid use or abuse.
BONE AND CONNECTIVE TISSUE
The issue of anabolic steroids and bone growth has
been examined in both young and adult populations.
In both populations, androgens have been
successfully used as part of the treatment for growth
delay (Albanese et al., 1994; Bagatell and Bremner,
1996; Doeker et al., 1998), and for osteoporosis in
women (Geusens et al., 1986). Androgens are bi-
phasic in that they stimulate endochondral bone
formation and induce growth plate closure at the end
of puberty. The actions of androgens on the growth
plate are mediated to a large extent by aromatization
to estrogens (Vanderschueren et al., 2004; Hoffman,
2002). Anabolic steroid use results in significant
elevations in estrogens thought to impact premature
closure of the growth plate. The acceleration of
growth in adolescents treated with testosterone has
raised concern for the premature closure of the
epiphyseal plate (NIDA, 1996; Sturmi and Diorio,
1998). However, there does not appear to be any
reports documenting the occurrence of premature
stunted growth in adolescents taking anabolic
steroids. Interesting, anabolic steroid administration
in colts has been reported to delay epiphyseal plate
closure (Koskinen and Katila, 1997). Although
comparisons between humans and animals are
difficult to make, suprapharmacological dosages that
most athletes use may pose a greater risk than the
doses studied to date. Thus, for the adolescent
athlete using anabolic steroids the risk of premature
epiphyseal plate closure may exist.
Anabolic steroids have been suggested to
increase the risk of tendon tears in athletes (David et
al., 1994; Stannard and Bucknell, 1993). Studies in
mice have suggested that anabolic steroids may lead
to degeneration of collagen (proportional to duration
of steroid administration) and potentially lead to a
decrease in tensile strength (Michna, 1986). In
addition, a decrease in collagen synthesis has been
reported from anabolic steroid administration in rats
(Karpakka et al., 1992). The response in humans has
been less clear. Mechanical failure has been
suggested as a mechanism in anabolic steroid-using
athletes. Skeletal muscle adaptations (i.e.
hypertrophy and strength increases) take place rather
rapidly in comparison to connective tissue.
Therefore, tendon injuries in athletes are thought to
occur from a rapid increase in training intensity and
volume where connective tissue fails to withstand
the overload. However, case reports of spontaneous
tendon ruptures of weightlifters and athletes are
limited. Although experimental data from animal
models suggest that anabolic steroids may alter
biomechanical properties of tendons, ultrastructural
evidence supporting this claim is lacking. One study
has shown that high doses of anabolic steroids
decrease the degradation and increase the synthesis
of type I collagen (Parssinen et al., 2000). Evans and
colleagues (1998) performed an ultrastructural
analysis on ruptured tendons from anabolic steroid
users. They concluded that anabolic steroids did not
induce any ultrastructural collagen changes that

Medical issues and anabolic steroids
187
would increase the risk of tendon ruptures.
Although the incidences of tendon rupture in
anabolic steroid users should not be discounted, it is
important to consider it in relation to the mechanical
stress encountered from the rapid increases in
muscular performance. Prospective research on
anabolic steroid use and connective tissue injury is
warranted.
PSYCHOLOGICAL AND BEHAVIORAL
An issue that is often raised with anabolic steroid
use is the psychological and behavioral effects.
Increases in aggressiveness, arousal and irritability
have been associated with anabolic steroid use. This
has potentially beneficial and harmful implications.
Elevations in arousal and self-esteem may be a
positive side effect for the athlete. The increase in
aggressiveness is a benefit that athletes participating
in a contact sport may possess. However, increased
aggressiveness may occur outside of the athletic
arena thereby posing significant risks for anabolic
steroid users and those they come in contact with.
Anabolic steroids are associated with mood swings
and increases in psychotic episodes. Studies have
shown that nearly 60% of anabolic steroid users
experience increases in irritability and
aggressiveness (Pope and Katz, 1994; Silvester,
1995). A recent study by Pope and colleagues (2000)
reported that significant elevations in aggressiveness
and manic scores were observed following 12 weeks
of testosterone cypionate injections in a controlled
double-blind cross-over study. Interestingly, the
results of this study were not uniform across the
subjects. Most subjects showed little psychological
effect and few developed prominent effects. A cause
and effect relationship has yet to be identified in
anabolic steroid users and it does appear that
individuals who experience psychological or
behavioral changes do recover when steroid use is
discontinued (Fudula et al., 2003).
ADDITIONAL ADVERSE EFFECTS
ASSOCIATED WITH ANABOLIC
STEROID USE
Other adverse events generally associated with
anabolic steroid use include acne, male pattern
baldness, gynecomastia, decreased sperm count,
testicular atrophy, impotence, and transient
infertility. Acne is one of the more common side
effects associated with anabolic steroid
administration. One study reported that 43% of users
experienced acne as a consequence from androgen
use (O’Sullivan et al., 2000). Few other
investigations have been able to prospectively
determine the occurrence of side effects associated
with androgen administration. Increases in acne are
thought to be related to a stimulation of sebaceous
glands to produce more oil. The most common sites
of acne development are on the face and back. Acne
appears to disappear upon cessation of androgen
administration.
Male pattern baldness does not appear to be a
common adverse effect, but is often discussed as a
potential side effect associated with androgen use.
This is likely related to the role that androgens have
in regulating hair growth (Lee et al., 2005). An
abnormal expression of a specific cutaneous
androgen receptor increases the likelihood of
androgenic alopecia (Kaufman and Dawber, 1999;
Lee et al., 2005). Thus, it is likely that androgenic
alopecia observed as a result of exogenous androgen
use is more prevalent in individuals that have a
genetic predisposition to balding.
Gynecomastia is a common adverse effect
associated with anabolic steroid use. Research has
demonstrated a prevalence rate of 37% in anabolic
steroid users (O’Sullivan et al., 2000). Gynecomastia
is a benign enlargement of the male breast resulting
from an altered estrogen-androgen balance, or
increased breast sensitivity to a circulating estrogen
level. Increases in estrogen production in men are
seen primarily through the aromatization of
circulating testosterone. Many anabolic steroid users
will use anti-estrogens (selective estrogen receptor
modulators) such as tamoxifen and clomiphene or
anastrozole which is a nonsteroidal aromatase
inhibitor to minimize side effects of estrogen and
stimulate testosterone production. Once
gynecomastia is diagnosed cosmetic surgery is often
needed to correct the problem.
Changes in libido appear to be the most
common adverse event (approximately 61% of
users) reported in a small sample of anabolic steroid
users (O’Sullivan et al., 2000). Although
testosterone is often used in hypogonadal men to
restore normal sexual function, increasing
testosterone above the normal physiological range
does not appear to increase sexual interest or
frequency of sexual behavior in healthy men
administered anabolic steroids in supraphysiological
dosages (up to 500 mg·wk-1) for 14 weeks (Yates et
al., 1999). Other studies confirm unchanged libido
following 10 weeks of anabolic steroid
administration in dosages ranging up to 200 mg·wk-1
(Schurmeyer, et al., 1984). However, reports do
indicate that towards the end of an androgen cycle
some men may experience loss of libido (O’Sullivan
et al., 2000). It was thought that the decreased libido
was related to the transient hypogonadism which

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188
typically occurs during exogenous androgen
administration. Decreases in libido as a result of
hypogonadism appear to be a function of high
baseline levels of sexual functioning and desire
(Schmidt et al., 2004). This may explain the
conflicting reports seen in the literature. Regardless,
changes in libido do appear to normalize once
baseline endogenous testosterone concentrations
return (Schmidt et al., 2004).
Another frequent adverse event relating to
sexual function in males administering anabolic
steroids is reversible azoospermia and oligospermia
(Alen and Suominen, 1984; Schurmeyer et al.,
1984). As exogenous androgen use increases,
endogenous testosterone production is reduced. As
a result, testicular size is reduced within three
months of androgen administration (Alen and
Suominen, 1984). In addition, sperm concentration
and the number of spermatozoa in ejaculate may be
reduced or eliminated by 7 weeks of administration
(Schurmeyer et al., 1984). During this time risk for
infertility is elevated. However, the changes seen in
testicular volume, sperm count and concentration are
reversible. Anabolic steroid-induced hypogonadism
returns to baseline levels within 4 months following
discontinuation of androgen use (Jarow and
Lipshultz, 1990), and sperm counts and
concentration return to normal during this time
frame (Alen and Suominen, 1984; Schurmeyer et al.,
1984).
MEDICAL ISSUES ASSOCIATED WITH
FEMALE STEROID USE
In female anabolic steroid users the medical issues
are quite different than that shown in men.
Deepening of the voice, enlargement of the clitoris,
decreased breast size, altered menstruation,
hirsutism and male pattern baldness are all clinical
features common to hyperandrogenism in females
(Derman, 1995). Androgen excess may occur as the
result of polycystic ovary syndrome, congenital
adrenal hyperplasia and possibly Cushing’s
syndrome (Derman, 1995; Redmond, 1995).
However, these clinical symptoms are seen in
young, female athletes that are self-administering
anabolic steroids. In contrast to men, many of these
adverse events in the female anabolic steroid user
may not be transient (Pavlatos et al., 2001).
LONG TERM HEALTH ISSUES
ASSOCIATED WITH ANABOLIC
STEROID ADMINISTRATION
The acute health issues associated with anabolic
steroid use appear to be transient and more prevalent
in individuals with genetic predisposition (e.g. hair
loss, heart disease). It is the long-term effects that
become a larger issue. However, limited data are
available. In one study in mice, anabolic steroids
were administered in relative dosages typically used
by bodybuilders. However, the duration of the study
was 1/5 the life span of the mouse which is
relatively greater than that experienced by most
athletes self-administering androgens. The results
demonstrated a shortened life span of the mice with
evidence of liver, kidney and heart pathology
(Bronson and Matherne, 1997). In a study on
Finnish power lifters, investigators examined 62
athletes who finished in the top 5 in various weight
classes between the years 1977 and 1982 (Parssinen
et al., 2000). These investigators reported that during
a 12-year follow-up, the mortality rate for the power
lifters was 12.1% compared to 3.1% in a control
population. They concluded that their study depicted
the detrimental long-term health effects from
anabolic steroid use. Others have suggested that
prolonged anabolic steroid use may increase the risk
for premature death, but this may be more relevant
in subjects with substance abuse or underlying
psychiatric disease (Petersson et al., 2006).
The use of anabolic steroids in strength/power
athletes has been reported for more than 50 years in
North America. As discussed in the beginning of this
review, during the 1970’s and 1980’s anecdotal
reports on the rampant use of anabolic steroids in
professional athletes were prevalent. However, little
information is available concerning steroid-related
diseases or associated deaths in these former
strength/power athletes who are now well into
middle age. Regardless, research should focus on
these former athletes to ascertain possible long-term
effects from androgen use.
IS THERE A CLINICAL ROLE OF
ANDROGENIC ANABOLIC STEROIDS?
The efficacy of anabolic steroids in enhancing
muscle strength and lean tissue accruement is no
longer an issue for debate. While the issue of
medical risks in individuals self-administering
anabolic steroids is still being hotly debated, the
medical community is no longer denying the
potential clinical use of these androgens (Dobs,
1999). In recent years clinical treatment with
anabolic steroids has increased lean tissue and
improved daily functional performance in AIDS
patients (Strawford et al., 1999) patients receiving
dialysis (Johansen et al., 1999), patients with chronic
obstructive pulmonary disease (Ferreira et al., 1998),
and patients recovering from a myocardial infarction
(Nahrendorf et al., 2003). In addition, research has

Medical issues and anabolic steroids
189
demonstrated a positive effect on healing from
muscle contusion injuries (Beiner et al., 1999).
Although the medical community has generally
taken a conservative approach to promoting anabolic
steroids as part of a treatment plan in combating
diseases involving muscle wasting, the body of
knowledge that has developed indicates the potential
positive effects of androgen therapy for certain
diseased populations.
CONCLUSIONS
For many years the scientific and medical
communities depicted a lack of efficacy and serious
adverse effects from anabolic steroid use. However,
competitive athletes continued to experiment with,
use, and abuse anabolic steroids on a regular basis to
enhance athletic performance despite the potential
harmful side effects. The empirical evidence that the
athletes viewed may have led to the development of
distrust between the athletic and medical
communities. Science has been lagging several years
behind the experimental practices of athletes. In fact,
most athletes consume anabolic steroids on a trial
and error approach based on information gained
from other athletes, coaches, websites, or gym
“gurus.” Science has lacked in its approach to study
anabolic steroids because only few studies have
examined long-term cyclical patterns, high doses,
and the effects of stacking different brands of
steroids. These practices are common to the athletic
community and not for the medicinal purposes of
anabolic steroid therapy. In addition, some athletes
(especially bodybuilders) have experimented with
drugs unbeknown to the medical community, i.e.
insulin, thyroid hormones, and site-specific
enhancers such as Synthol and Esiclene to name a
few.
When examining the potential medical issues
associated with anabolic steroid use, evidence
indicates that most known side effects are transient.
More so, few studies have been able to directly link
anabolic steroids to many of the serious adverse
effects listed. Although clinical case studies continue
to link anabolic steroid administration with
myocardial infarct, suicide, and cancer, the evidence
to support a cause and effect relationship is lacking
and it may be other contributing factors (i.e. genetic
predisposition, diet, etc.) play a substantial role and
potentiate the harmful effects from anabolic steroids.
Consistent physician monitoring is critical to the
athlete who consumes anabolic steroids. However,
many athletes may not undergo extensive medical
exams prior to androgen administration and few
physicians may be willing to provide such
monitoring.
The purpose of this review was not to support
or condone anabolic steroid use. Rather, the aim was
to discuss pertinent medical issues and provide
another perspective in light of the fact that many
anabolic steroids users do not appear to prioritize the
health/safety hazards or potential adverse medical
events. In order to maintain credibility with the
athlete, it is important to provide accurate
information to the athlete in regards to these
performance enhancing drugs, and provide
education about alternative means and potential
risks. Finally, anabolic steroids have been used
legitimately for several clinical purposes such as
muscle wasting or hypogonadal related diseases.
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193
AUTHORS BIOGRAPHY
Jay R. HOFFMAN
Employment
The College of New Jersey
Degree
PhD
Research interests
Sport supplementation, resistance training, eExercise
endocrinology.
E-mail: hoffmanj@tcnj.edu
Nicholas A. RATAMESS
Employment
The College of New Jersey
Degree
PhD
Research interests
Sport supplementation, resistance training, exercise
endocrinolgy
E-mail: ratamess@tcnj.edu
KEY POINTS
• For many years the scientific and medical
communities depicted a lack of efficacy and
serious adverse effects from anabolic steroid
use.
• Clinical case studies continue to link anabolic
steroid administration with myocardial infarct,
suicide, and cancer, evidence to support a
cause and effect relationship is lacking.
• It may be other contributing factors (i.e.
genetic predisposition, diet, etc.) that play a
substantial role and potentiate the harmful
effects from anabolic steroids.
 Jay R. Hoffman, Ph.D., FACSM, CSCS*D
Department of Health and Exercise Science, The College
of New Jersey, PO Box 7718, Ewing, New Jersey 08628,
USA.